Diabetes in pregnancy: are we providing the best care ... - HQIP

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A comparison of type 1 and type 2 diabetes 11.5 Preconception care in the 12 months prior to pregnancy There were no differences between women with type 1 and type 2 diabetes in terms of the contraceptive advice, specifi c diabetes advice and information about pregnancy risks and surveillance provided by clinicians before pregnancy (table 11.6) However, women with type 2 diabetes were less likely to have a retinal examination and assessment of albuminuria than women with type 1 diabetes in the 12 months before pregnancy (p=0.004, p=0.04 respectively, table 11.6). Table 11.6 Differences in preconception care between women with type 1 and type 2 diabetes Women with type 1 diabetes n/N (%) Women with type 2 diabetes n/N (%) p-value No contraceptive advice given 18/76 (24) 18/44 (41) 0.05 No recorded discussion of the following specifi c diabetes issues: Alcohol intake 16/57 (28) 8/30 (27) 0.09 Diet 10/82 (12) 5/56 (9) 0.55 Poor glycaemic control 12/102 (12) 4/60 (7) 0.29 Retinopathy 17/80 (21) 11/37 (30) 0.31 Nephropathy 21/64 (33) 14/29 (48) 0.15 Hypertension 19/64 (30) 11/32 (34) 0.64 No recorded discussion of the following pregnancy issues: Increased diabetes surveillance 7/109 (6) 4/57 (7) 0.88 Increased pregnancy surveillance 8/109 (7) 4/56 (7) 0.96 Increased risk of induction 13/95 (14) 8/40 (20) 0.36 Possible caesarean section 11/93 (12) 6/47 (13) 0.87 Fetal risks in diabetic pregnancy 7/97 (7) 4/48 (8) 0.81 No dietetic review 87/110 (79) 19/77 (25) 0.19 No assessment of the following diabetes complications in the 12 months prior to pregnancy: Baseline retinal examination 12/122 (10) 17/66 (26) 0.004 Baseline test of renal function 10/115 (9) 21/175 (12) 0.06 Assessment of albuminuria 20/92 (22) 21/56 (38) 0.04 Assessment of suboptimal preconception care (apart from glycaemic control) 72/116 (62) 53/72 (74) 0.1 11.6 Glycaemic control There was no difference in the proportion of women with type 1 or type 2 diabetes having a test of glycaemic control in the 12 months before pregnancy (table 11.7). This was different to the fi ndings of the descriptive study, where women with type 2 diabetes were less likely than women with type 1 diabetes to have documented evidence of a pre-pregnancy test of glycaemic control. 2 This may be because the 76
enquiry related to a 12 month prior to pregnancy rather than 6 months as for the descriptive study. Also, in the descriptive study, information was dependent on documentation in the maternity notes whereas in the enquiry, the adult diabetes service and general practitioner were also approached for information, and this may have resulted in increased ascertainment. Women with type 1 diabetes were more likely than women with type 2 diabetes to have suboptimal preconception glycaemic control as assessed by enquiry panels (table 11.7). This was similar to the descriptive study, where only 24% of 1081 women with type 1 diabetes had a median HbA1c less than 7% prior to pregnancy compared to 41% of 303 women with type 2 diabetes. 2 Fewer women with type 2 diabetes received intravenous insulin and dextrose during delivery (table 11.7). This fi nding may partly refl ect the fact that a proportion of women with type 2 diabetes do not require insulin during pregnancy. Also, women with type 2 diabetes were more likely to be multiparous 2 , and there may have been no opportunity in labour to commence intravenous insulin and dextrose. Table 11.7 Differences in factors related to glycaemic control between women with type 1 and type 2 diabetes Women with type 1 diabetes n/N (%) Women with type 2 diabetes n/N (%) p-value No test of glycaemic control in the 12 months prior to pregnancy 20/120 (17) 14/73 (19) 0.66 No evidence of local targets set for glycaemic control 24/73 (33) 11/34 (32) 0.96 Assessment of suboptimal preconception glycaemic control 105/140 (75) 58/97 (60) 0.013 Assessment of suboptimal 1st trimester glycaemic control 104/160 (65) 66/122 (54) 0.064 Assessment of suboptimal glycaemic control after 1st trimester 71/174 (41) 46/130 (35) 0.34 Assessment of suboptimal blood glucose control during labour and 78/165 (47) 49/120 (41) 0.28 delivery No intravenous insulin and dextrose during labour and/or delivery 18/180 (10) 38/133 (29)
Page 1 and 2:
Confidential Enquiry into Maternal
Page 3 and 4:
Contents Acknowledgements .........
Page 5 and 6:
• Members of the CEMACH Diabetes
Page 7 and 8:
Erb’s palsy Injury to the nerve r
Page 9 and 10:
Neonatal unit A unit which provides
Page 11 and 12:
Foreword This third and fi nal repo
Page 13 and 14:
1. Introduction This is the fi nal
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2. Key fi ndings of the CEMACH Diab
Page 17 and 18:
Suboptimal fetal surveillance of ba
Page 19 and 20:
3. Summary of recommendations This
Page 21 and 22:
2. Patient pathways of care includi
Page 23 and 24:
the pregnancies meeting this defi n
Page 25 and 26:
in order to remove any identifi abl
Page 27 and 28:
When deriving odds ratios for any p
Page 29 and 30:
Associations are reported in Chapte
Page 31 and 32:
Table 5.1 Characteristics of women
Page 33 and 34:
Table 5.4 Characteristics of women
Page 35 and 36:
was no information available to pan
Page 37 and 38: 6. Factors associated with poor pre
Page 39 and 40: Table 6.2 Association of clinical c
Page 41 and 42: Table 6.5 Association of specifi c
Page 43 and 44: Table 6.8 Association of postnatal
Page 45 and 46: folic acid before pregnancy (19% of
Page 47 and 48: Table 7.2 Panel comments on social
Page 49 and 50: 7.5 Conclusions One of the key fi n
Page 51 and 52: 11.Dex S, Heather J (eds). Millenni
Page 53 and 54: 8. Clinical care issues: preconcept
Page 55 and 56: chance of induction of labour was r
Page 57 and 58: 8.6.1 Enquiry fi ndings Just over h
Page 59 and 60: Some quotes from the panel discussi
Page 61 and 62: Apart from the explanation of pregn
Page 63 and 64: was associated with poor pregnancy
Page 65 and 66: of women after the fi rst trimester
Page 67 and 68: 9.5.1 Panel comments on suboptimal
Page 69 and 70: During labour and delivery, the maj
Page 71 and 72: Just 52% of 383 women (38% of 164 c
Page 73 and 74: • ‘No serial growth scans perfo
Page 75 and 76: The panel enquiries, which are in e
Page 77 and 78: 10.3.1 Enquiry fi ndings Seventy fi
Page 79 and 80: 10.6 Communication Effective commun
Page 81 and 82: Some quotes from the panel discussi
Page 83 and 84: working between primary and seconda
Page 85 and 86: we therefore selected 7.2% of pregn
Page 87: 11.4 Preconception behaviour The CE
Page 91 and 92: Table 11.10 Differences in postnata
Page 93 and 94: Type 1 and type 2 diabetes have tra
Page 95 and 96: Panels were chaired by the panel ch
Page 97 and 98: In 57% (24/42) of cases, a junior d
Page 99 and 100: Infant formula given as fi rst feed
Page 101 and 102: 2.1 hours in babies remaining with
Page 103 and 104: 12.7.1 Panel comments on suboptimal
Page 105 and 106: The concerns described here probabl
Page 107 and 108: External commentary Patricia Hamilt
Page 109 and 110: informed and motivated to manage th
Page 112 and 113: 100 Appendix A: Pre-pregnancy care
Page 114 and 115: 102 Appendix B: Diabetes enquiry pr
Page 132 and 133: Appendix C Association between demo
Page 134 and 135: Appendix C Association of preconcep
Page 136 and 137: Appendix C Association of postnatal
Page 138 and 139:
Appendix D Association of social an
Page 140 and 141:
Appendix D Association of diabetes
Page 142 and 143:
Appendix E Association between demo
Page 144 and 145:
Appendix E Association between prec
Page 146 and 147:
Appendix E Association between post
Page 148 and 149:
Appendix F - CEMACH advisory groups
Page 150:
Appendix F - CEMACH advisory groups
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Diabetes in pregnancy: are we providing the best care ... - HQIP

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